FAST TRACK FORM

Step 1 of 4 - Choose Category

Choose Professional Healthcare Services

There are 5 main category fields. Please select one of the category and proceed with the "Next" button below after you have selected and confirm the yearly premium.

Healthcare Services

Categories

Limit of Coverage (Per Year):

Categories

Limit of Coverage (Per Year):

Categories

Limit of Coverage (Per Year):

Categories

Limit of Coverage (Per Year):

Categories

Non-invasive elective topical enhancement of patient’s external appearance including injection or minor procedure

Care of Patient and Management of Pregnancy Beyond 24 weeks Gestation Excluding Deliveries

Limit of Coverage (Per Year) with Locum:

Your Yearly Premium is: (includes SST and stamp)

Consent

IMPORTANT NOTICE TO THE APPLICANTS

Your duty of disclosure

You have the duty to disclose to Chubb Insurance Malaysia Berhad or Syarikat Takaful Malaysia Berhad ( Chubb , us , we , our , STMB ) any matter that:(a) You know to be relevant to our decision on whether to accept the risks or not and the rates and terms to be applied; or (b) a reasonable person in circumstances could be expected to know to be relevant.
You have the duty to disclose those matters to Us before you renew, extend , vary or reinstate a contract of general insurance,

Non-Disclosure

If you fail to comply with duty of disclosure, We May have the option of avoiding the contract of insurance from its beginning. If you non-disclosure is fraudulent, We may also have the right to keep the premium that you have paid.

Change of Risks or circumstances

You should advice US as soon as practicable of any change to your normal business as disclosed in this application.

Subrogation

Where you have agreed with another person or company, who would otherwise be liable to compensate you for any loss or damage which is covered by the policy , that you will not seek to recover such loss or damage from that person , Chubb or STMB will not covet you to the extent permitted by law , for such loss or damage.

Name(Required)

IC Number(Required)

Phone(Required)

Email(Required)

Clinic / Hospital Address(Required)

Address Line 1 Address Line 2 City State Poscode

Type of Application

Qualification

Please state: 1) Institution Name 2) Degree/Qualification 3) In what year obtained

Details of Registration

Please state 1) Licensing body 2) Registration number 3) Registration date

Insurance History - Are you having any existing medical malpractice insurance?(Required)

Yes

Period of Insurance / Company and Policy Limit.

Claim History - Have any claims been made against you ; aware of any circumstances & allegations being made against you ; have you been the subject of disciplinary action by professional body ; have you had criminal charges brought against you ?(Required)

Yes

Please provide full details and status of each claim.

Declaration(Required)

Declaration & Signature

- I have read and understood the importance notices contained in this application.
- I agree that this proposal together with any other information will form the basis of any contract of insurance.
- I acknowledge that if this application is accepted, the contract of insurance will be subject to terms and conditions as set out in the policy wording as issued or as otherwise specifically varied in writing by Chubb or STMB
- I declare after inquiry that the statement, particulars and information contained in this application and in any document accompanying this application are true and correct in every detail and that no other material facts have been misstated, suppress or omitted .
- I undertake to inform Chubb or STMB of any material alteration to those facts before completion of the contract of insurance.
- I understand the Chubb or STMB needs to deal with our personal data to administer our Policy and offer us insurance products and services . To achieve these purpose ,I allow Chubb or STMB to collect, use and disclose our personal data to selected third parties in or outside Malaysia, in accordance with Personal Data Protection Notice

Signature(Required)

Payment Method

All Premium Amount included SST 6%. We are now support online payment gateway through SecurePay for better experience. RM1.50 will be charge for every transaction.

Your Total Premium is:

Choose Payment Method(Required)

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